Use of an electronic referral system to improve the outpatient primary care–specialty care interface

Final ACTION Contract Report Use of an Electronic Referral System to Improve the Outpatient Primary Care–Specialty Care Interface Implementation Handbook This page intentionally left blank Use of an Electronic Referral System to Improve the Outpatient Primary Care–Specialty Care Interface Implementation Handbook Prepared for: Agency for Healthcare Research and Quality U.S Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Contract No HHSA 290200600017, TO #3 Prepared by: RAND Corporation, Santa Monica, CA Authors: Douglas S Bell Susan G Straus Shinyi Wu Alice Hm Chen Margot B Kushel AHRQ Publication No 11(12)-0096-1-EF February 2012 This document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders Suggested Citation: Bell DS, Straus SG, Wu S, Chen AH, Kushel MB Use of an Electronic Referral System to Improve the Outpatient Primary Care–Specialty Interface: Implementation Handbook (Prepared by RAND Corporation under Contract No HHSA 290-2006-00017, TO #3) AHRQ Publication No 11(12)-0096-1-EF Rockville, MD: Agency for Healthcare Research and Quality February 2012 None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report This project was funded by the Agency for Healthcare Research and Quality (AHRQ), U.S Department of Health and Human Services The opinions expressed in this document are those of the authors and not reflect the official position of AHRQ or the U.S Department of Health and Human Services ii Preface This project was funded as an Accelerating Change and Transformation in Organizations and Networks (ACTION) task order contract ACTION is a 5-year implementation model of fieldbased research that fosters public–private collaboration in rapid-cycle, applied studies ACTION promotes innovation in health care delivery by accelerating the development, implementation, diffusion, and uptake of demand-driven and evidence-based products, tools, strategies, and findings ACTION also develops and diffuses scientific evidence about what does and does not work to improve health care delivery systems It provides an impressive cadre of deliveryaffiliated researchers and sites with a means of testing the application and uptake of research knowledge With a goal of turning research into practice, ACTION links many of the Nation's largest health care systems with its top health services researchers For more information about this initiative, go to http://www.ahrq.gov/research/action.htm iii What Is eReferral? A HIPAA-compliant, Web-based referral and consultation system • • • Linked to electronic medical record (EMR), with auto-population of relevant EMR data Referring providers enter free text referral questions Mandatory use for enrolled specialty clinics A new model for primary care – specialty care collaboration • • Individualized review and response to each referral by a designated specialist clinician (MD or NP) Iterative communication between referring and reviewing clinicians until both agree that the patient either does not need an appointment or the appointment is scheduled A tool that allows specialist reviewers to— • • • • Redirect referrals if inappropriate for clinic or other options available Provide information for PCP management of condition, with or without an appointment Request clarification of question or additional workup prior to specialty appointment Expedite specialty clinic appointments if clinically warranted For more information on eReferral, contact Alice Chen at achen@medsfgh.ucsf.edu iv Contents Statement of the Problem The Delivery System Referral Process Prior to eReferral eReferral History Technical Specifications eReferral Overview eReferral Submission Process Initial Specialist Review 15 Specialist Reviewer Tools 18 Scheduling Process 21 Scheduled Appointments 22 Not Scheduled eReferrals 27 eReferral Documentation and Management 29 eReferral Support 37 Clinic Implementation Process 40 Ongoing Improvements 41 Impact of eReferral 41 Decrease in Wait Times 41 High Levels of Primary Care Provide Acceptability 42 Improvements in Specialist Experience 42 Table Table Wait times (in days) for the next available new patient appointment for four different medical specialty clinics Figures Figure San Francisco General Hospital’s Core Referral Network Figure Overview of computer networks accessing eReferral Figure Sample completed referral form Figure eReferral submission process Figure Referral submission process with step highlighted Figure Patient search window Figure Initial eReferral window Figure Specialty clinic or service selection window Figure Referring provider screening questions window Figure 10 Referring provider screening questions window with reason Figure 11 Sample urology clinic policy window, and posted pre-referral guidelines window 10 Figure 12 Referring provider selection window 11 Figure 13 Referring provider location window 11 Figure 14 Attending provider selection window 12 v Figure 15 Patient information window 12 Figure 16 Standardized clinical information selection window 13 Figure 17 Initial specialist review window 13 Figure 18 Referral submission process with steps 2, 3, highlighted 14 Figure 19 Reviewer response to referring provider window 14 Figure 20 Referral submission process with steps 3, 4, highlighted 15 Figure 21 Scheduling instructions window 15 Figure 22 Clinic configuration window 16 Figure 23 eReferral news window 16 Figure 24 Diagnostic test results window 17 Figure 25 Test results window with consult and lab results 17 Figure 26 Boilerplate library table 18 Figure 27 Access and role settings for clinic 18 Figure 28 Scheduler view with schedule lists 19 Figure 29 Scheduled appointment 20 Figure 30 Consultant view of scheduled appointments 20 Figure 31 Scheduled appointment with running notes 21 Figure 32 Scheduled appointment with multiple dated notes 21 Figure 33 Appointment list 22 Figure 34 Outpatient eReferral form 22 Figure 35 Scheduled appointment 23 Figure 36 Referral submission process with steps 1, 3, 4, 5, highlighted 23 Figure 37 Current request status 24 Figure 38 Consultant view 25 Figure 39 Patient’s EMR 26 Figure 40 Referring provider worklist 27 Figure 41 Primary care provider worklist 28 Figure 42 Referring location worklist 29 Figure 43 Primary care clinic worklist 30 Figure 44 Referring provider removing eReferral from worklist for designated time 31 Figure 45 eReferral being returned to worklist 31 Figure 46 Referring provider worklist 32 Figure 47 Referring location worklist 32 Figure 48 Change referring provider tool 33 Figure 49 Audit trail for the eConsult to patient 33 Figure 50 eReferral suggestion box 34 Figure 51 eReferral help and FAQs 35 Figure 52 eReferral news archives 36 Figure 53 Clinics and services requiring eReferral 36 Figure 54 eReferral activity chart and reviewer audit 37 Appendix Appendix A: Acknowledgments A-1 vi University of California, San Francisco (UCSF), San Francisco General Hospital (SFGH) eReferral Program Statement of the Problem Over the past decade, access to specialty care has become arguably one of the most pressing issues for safety net providers and patients across the country, with wait times for some specialties extending to nearly a year There is a dearth of specialists, particularly surgical specialists, who are willing to see uninsured and Medicaid patients, resulting in a severe mismatch between supply of and demand for specialty services Compounding this crisis are inefficient referral processes notable for poor or absent communication between referring and specialty providers, and systems dependent on handwritten referrals and unreliable faxes to schedule appointments San Francisco is no exception San Francisco General Hospital (SFGH), through a partnership with the University of California, San Francisco (UCSF), serves as the primary provider of specialty care for the city’s 72,000 uninsured as well as many of its Medi-Cal and Medicare patients Prior to eReferral, the wait time for some routine specialty appointments was as long as 11 months If a referring provider wanted to expedite her patient’s appointment, she had to try to reach (call, email, or page) and convince a specialist of the urgency of the request There was no equitable mechanism for specialists to triage urgent cases, as they only heard about patients when the referring provider made an extra effort to contact them When the patient did present for care, the specialist would often find that the initial evaluation was either incomplete or had not been forwarded, or that the consultative question was unclear Sometimes the referral was unnecessary Less frequently, but more concerning, the specialist might find that the patient’s case was urgent and should have been seen earlier The system was frustrating to primary care providers, specialists, and patients alike The Delivery System San Francisco General Hospital is part of the San Francisco Department of Public Health (DPH), which also includes a network of community clinics and a skilled nursing facility The City’s sole public hospital, SFGH operates 252 acute care beds In fiscal year 2007-2008, SFGH provided 529,098 outpatient visits, 29 percent of which were specialty care visits and 20 percent of which were for diagnostic services The payer mix for these visits was 34 percent uninsured, 28 percent Medi-Cal and 18 percent Medicare Major specialty clinics at SFGH include (but are not limited to) cardiology, dermatology, endocrinology, gastroenterology, general surgery, hematology-oncology, nephrology, neurology, neurosurgery, obstetrics and gynecology, ophthalmology, orthopedics, otolaryngology, plastic surgery, podiatry, pulmonary, rheumatology and urology SFGH’s physician services are provided by UCSF faculty, fellows and residents The hospital currently uses a hybrid paper and electronic medical record (EMR) Figure San Francisco General Hospital’s Core Referral Network SFGH’s core referral network for specialty clinics consists of a diverse group of 27 primary care clinics that have differing levels of access to the DPH electronic medical record (EMR) (see Figure 1) The clinics include hospital-based primary care clinics, 12 Community-Oriented Primary Care (COPC) clinics, and 10 San Francisco Community Clinic Consortium (SFCCC) clinics Referrals for diagnostic studies (e.g., MRI) originate from both primary care and specialty clinics • • • Hospital-based primary care clinics include family medicine, internal medicine, pediatrics, positive health (HIV primary care), and women’s health clinics The family medicine, internal medicine, pediatrics, and women’s health clinics serve as continuity clinic training sites for UCSF residents While the physicians are UCSF employees, the clinic staff are city employees Together, these five clinics serve as primary care home for more than 30,000 patients These clinics have immediate access to the DPH EMR, with all but the women’s health clinic having computer terminals in each patient care room COPC clinics include a network of twelve primary care clinics located in neighborhoods across San Francisco that together serve as the primary care home for nearly 45,000 patients Both physician and clinic staff are City employees Each of the clinics has reliable access to the DPH EMR Many, but not all, COPC clinics have terminals in each patient care room Consortium clinics consist of 10 independent clinics, including Federally Qualified Health Centers and three free clinics SFCCC clinics together serve over 70,000 people per year Each health center employs its own physicians and clinic staff, and each has a local Practice Management System whose primary function is billing; two have an EMR Connectivity to the DPH Network and EMR is provided via a limited number of workstations configured with the DPH’s VPN (Virtual Private Network) software Primary Care Provider Worklist: displays all eReferrals for a given primary care provider’s patients, regardless of who made the referral Figure 41 Primary care provider worklist 28 Referring Location Worklist: displays all eReferrals originating from a given clinic Figure 42 Referring location worklist 29 Primary Care Clinic Worklist: displays all eReferrals for patients assigned to a given primary care clinic Figure 43 Primary care clinic worklist 30 Several other functions have been developed in order to enhance the referring provider’s ability to actively manage his eReferrals He has the ability to temporarily remove eReferrals from his worklist for a designated time period Figure 44 Referring provider removing eReferral from worklist for designated time After that period has elapsed, the eReferral is flagged and returned to his worklist and the provider is notified via an automated email to check the worklist This serves as a tickler system for the referring provider, for example, in the case of a referral where the specialist reviewer has requested additional lab results prior to deciding whether the patient needs an appointment Figure 45 eReferral being returned to worklist 31 Providers are also able to communicate with their clinics’ support staff via a “Non-Clinical Note” that is also displayed on the clinic worklist This serves to relieve the provider of administrative tasks such as filling out lab requisitions and calling the patient to come in for the test Figure 46 Referring provider worklist Figure 47 Referring location worklist 32 When a patient changes primary care providers, her new PCP has the ability to change the referring provider to herself, which then automatically transfers the eReferral to her Referring Provider Worklist Figure 48 Change referring provider tool Finally, there is an audit function for every eReferral that tracks all activity from the time of submission, including who viewed the eReferral, any decisions made by the specialist reviewer, and any scheduling activity Each action is automatically name, date, and time stamped Figure 49 Audit trail for the eConsult to patient 33 eReferral Support Suggestion Box: We encourage users to contact us with any problems with or suggestions for improving the program We depend on this function to quickly identify problems with the program Figure 50 eReferral suggestion box 34 eReferral FAQs: We have developed a series of Frequently Asked Questions and responses largely based on Suggestion Box submissions and questions from outreach and training sessions Figure 51 eReferral help and FAQs 35 eReferral News Archives: We primarily use email to communicate with our large number of institutionally dispersed users All eReferral-related emails are archived for users’ reference Figure 52 eReferral news archives Clinics and Services requiring eReferral: This list is updated each time a new clinic or service begins to use eReferral Figure 53 Clinics and services requiring eReferral 36 eReferral Activity Chart and Reviewer Audit: We have developed a report that displays the volume and disposition of eReferrals by clinic for a designated time period This can be used to track changes in volume of referrals It is also used by administrative staff to monitor specialist reviewer response rates on a weekly basis; reviewers who have a backlog of pending eReferrals are contacted by email Figure 54 eReferral activity chart and reviewer audit Clinic Implementation Process Each specialty clinic or service interested in adopting eReferral must identify one or two specialist clinician reviewers who agree to review eReferrals on a regular, timely basis; referring providers expect to receive an automated email alert regarding their referral within business days Reviewers must be a licensed independent practitioner (MD or NP) who (1) has specialty knowledge and expertise covering the broad range of conditions that are referred to the clinic, (2) who is familiar with the SFGH specialty clinic’s operations through regular patient care in the clinic, and (3) will be at SFGH for at least one year (i.e., rotating residents and fellows are not eligible to serve as reviewers) For NPs, an attending physician, either the Clinic Chief or Service Chief, serves as the supervising physician At this time, the medical specialties have physician reviewers, while all but one of the surgical clinics have NP reviewers 37 Each clinic must also identify designated clerical personnel to staff the specialty clinic’s scheduling worklist These clerical staff are hospital employees who receive training to use the eReferral program Ideally, these individuals have basic facility with computers and internet programs, but the selection of the assigned clerical staff is the decision of each clinic’s Nurse Manager The eReferral Team works with the clinic to develop appropriate screening questions, policy page, and any additional modifications that are needed These additions and modifications are then added by the eReferral IS staff to the eReferral development server for testing If there are significant modifications from the basic intake form (e.g., MRI, CT), the program is piloted in one or two clinics prior to being implemented system-wide Two weeks prior to a clinic or service conversion to eReferral, an email is sent notifying all providers of the conversion; after the start date, all paper and faxed referrals are returned to the referring provider to be resubmitted as an eReferral During the week before conversion, the clerk(s) meet with a trainer to learn how to use the scheduler’s worklist Immediately after the clinic begins using eReferral, the designated specialist reviewer meets with the eReferral specialty lead to learn how to use the consultant worklist, and the clerks meet again with the trainer to resolve any questions or problems they have encountered Ongoing Improvements One important feature of the eReferral program is the relative ease with which the program can be modified to meet the needs of the users Many of the program’s current functions are a result of specific suggestions from referring providers, specialist reviewers, or clerical staff who use eReferral The eReferral team actively solicits feedback through structured surveys as well as through informal forums and the Suggestion Box Impact of eReferral Decrease in Wait Times We measured median wait times before and after the implementation of eReferral We also tracked the percentage of referrals that— a were not initially scheduled (these referrals were either inappropriate for the clinic, could be managed by the referring provider with some guidance from the specialist reviewer, needed additional diagnostic testing prior to appointment, or required clarification; prior to eReferral these would have resulted in the next available appointment), b resulted in expedited appointments (this represents the triage function of eReferral; prior to eReferral these would have been scheduled without regard to clinical urgency unless the referring provider attempted to contact a specialist to plead the patient’s case), and c were never scheduled (defined as a referral that did not result in an appointment within 180 days after the last exchange between the referring provider and the specialist reviewer) During the first months after implementing eReferral, median wait times for non-urgent visits declined in of medical specialty clinics by up to 90 percent (range 17 - 90 percent, all 38 but one greater than 60 percent) In these same clinics, data from January 2007- June 2009 show the percentage of referrals that were not initially scheduled ranged between 22 and 67 percent The percentage of referrals that were expedited (defined as an appointment scheduled before the routinely next available appointment) ranged from to 37 percent The percentage of referrals that were “never scheduled” ranged from 16 to 53 percent (unpublished data) High Levels of Primary Care Provider Acceptability Referring provider acceptability was gauged through a Web-based survey of primary care provider experience Among primary care providers, 71 percent felt that eReferral improved clinical care, 71 percent felt that eReferral provided improved guidance for pre-visit evaluation, and 89 percent felt that eReferral improved their ability to track referrals (Kim Y, Chen AH, Keith E, et al Not perfect, but better: primary care providers’ experiences with electronic referrals in a safety net health system J Gen Intern Med 2009; 24(5):614-9.) Improvements in Specialist Experience Impact on specialists was assessed through an encounter-based survey of new patient appointments comparing patients referred using the prior (paper and fax based) referral process and those referred through eReferral The reason for referral was difficult to identify in 19 percent and 39 percent of medical and surgical clinics using paper-based methods and in 10 percent of those using eReferral (Kim-Hwang JE, Chen AH, Bell D, et al “Evaluating the effect of electronic referrals for specialty care at a public hospital.” J Gen Intern Med 2010 Oct;25(10):1123-8.) 39 .This page intentionally left blank 40 Appendix A Acknowledgments The eReferral Team Alice Hm Chen, M.D., M.P.H Project Lead Kjeld Molvig Informatics Lead Ellen Keith Project Coordinator Nancy Parker, R.N Administrative Liaison Margot B Kushel, M.D Evaluation Lead Hal F Yee, Jr., M.D., Ph.D Specialty Lead Informatics Team Robert Brody, M.D Physician Liaison Specialty Team Julia Galletly, NP Surgery Lead Mark Ristich IT Consultant Nancy Omahen, NP Radiology Reviewer Fred Strauss, M.D Physician Liaison Alex Rybkin, M.D Radiology Lead eReferral Medicine Reviewers eReferral Surgery Reviewers Cardiology: Mary Gray Endocrinology: Suneil Koliwad, Lisa Murphy Gastroenterology/Liver: Hal Yee Hematology: Brad Lewis Pulmonary: Janet Diaz Renal: Sam James Rheumatology: John Imboden Breast Surgery: Kelly Ross-Manashil with Peggy Knudson ENT: Christina Herrera with Andrew Murr General Surgery: Danielle Evans with Michael West Orthopedics: Dan Bertheau Dorothy Christian, Brenda Stengele with Ted Miclau Neurology: Sean Braden with Cheryl Jay Neurosurgery/Neurotrauma: Sean Braden, Julia Galletly, Twila Lay with Geoff Manley Plastics: Erin Fry with Scott Hanson Urology: Bradley Erickson, Jeremy Meyers, Brian Voelzke Podiatry: Erika Eshoo with Sandra Martin eReferral Radiology Reviewers MRI and CT: Nancy Omahen, Alex Rybkin A-1 eReferral Women’s Health Reviewers Breast Evaluation: Diane Carr, Mary Scheib with Judy Luce Gynecology: Rebecca Jackson Obstetrics: Rebecca Jackson SF Department of Public Health Community Clinics Michael Drennan, Lisa Johnson, Barry Zevin San Francisco General Hospital and Trauma Center eReferral Evaluation DGIM fellow, PCP Survey: Yeuen Kim Medical student, Specialist Survey: Judy Hwang Analysts: David Guzman, Ryan Kimes RAND Terry Dentoni, Gene O’Connell, Roland Pickens San Francisco Health Plan Jean Fraser, Rafael Gomez, Ellen Kaiser, Alison Lum, Kelly Pfeifer Doug Bell, Susan Straus, Shinyi Wu University of California, San Francisco San Francisco Community Clinic Consortium Andy Bindman, Talmadge King John Gressman, David Lown, Lisa Pratt A-2